Medicare Eligibility Specialist

WelbeHealth

11h

About The Position

At WelbeHealth, we serve our communities’ most vulnerable seniors through shared intention, pioneering spirit, and the courage to love. These core values and our participant-focus lead the way no matter what. The Eligibility Specialist is accountable for proactively addressing complex eligibility challenges and ensuring seamless participant coverage. This role works directly with CMS, DHCS, and county Medicaid offices to troubleshoot eligibility issues, correct misalignments, and advocate for participants’ eligibility for the PACE program. This role also plays a key part in training internal teams, including Outreach & Enrollment and Social Work teams, to enhance organizational knowledge and prevent eligibility-related disruptions. This role is different because the Eligibility Specialist at WelbeHealth: Plays a critical role in securing life-sustaining coverage for vulnerable seniors, working hand-in-hand with Medi-Cal, Medicare, and Social Security agencies to remove barriers so participants can access comprehensive PACE services without interruption. Operates at the intersection of outreach, enrollment, eligibility, and revenue cycle, giving this role broader visibility and impact than traditional eligibility positions, and directly influencing program access and participant experience.

Requirements

Associate’s degree in relevant field; relevant experience may be substituted
Minimum of three (3) years of experience in Medicare is a must for the role
Minimum of one (1) year of experience working with governmental agencies
Excellent leadership, organizational and communication skills in settings with seniors, their families and interdisciplinary team members
Experience leading in a data-driven organization, leveraging reports and data to prioritize and manage people and projects

Nice To Haves

Over three (3) years of experience in Medicare eligibility

Responsibilities

Act as an organizational expert in Medicare or Medicaid eligibility policies and keep teams informed of regulatory updates
Provide guidance to leadership, internal teams, and stakeholders on eligibility cases, processes, and compliance requirements
Oversee resolution of complex eligibility issues, including coverage misalignments, retroactive enrollments, reinstatements, and eligibility corrections
Work directly with CMS, DHCS, and county agencies to troubleshoot eligibility discrepancies and secure accurate benefit assignments
Advocate for participants in disputed eligibility cases to minimize gaps in coverage
Develop and deliver training programs for internal teams to improve eligibility accuracy and efficiency, as well as maintain knowledge repositories, job aids, and process documentation to support staff in handling eligibility cases
Monitor and analyze enrollment and eligibility data (e.g., DTRR, 834, 820, MMR) to identify trends, discrepancies, and risks